EHR-S Records Management & Evidentiary Support (RM-ES) Work Plan / 2010

EHR-S FM Release 2 Update with RM-ES Functions: March 2010 – July 2010:

Project / Timeline / Notes
Act/Act Record Language
  • Develop language for the EHR-S FM & RM-ES profile that incorporates concept of an Act/Act Record

Metadata Review and Update
  • Evaluate the current audit record and metadata language in the EHR-S FM R2 and compare against:

  • Interoperability Model & CDA (Reconcile) – Issues identified in the following areas:
  • Metadata for cloning originating source
  • Metadata for originating application
  • Act date/time stamp & Act Record date/time
  • Location of the Act is not clearly identified in RM-ES
  • Metadata: Evaluate device/network location function/criteria in RM-ES. Is it even necessary to collect and/or retain this information? Check to see if this is captured in the security domain and may be part of their records.
  • (Metadata) Point of record content translation: Gap – need to clarify translation and then determine best approach
  • (Metadata) Point of record transmittal or disclosure. Address gap in metadata to maintain a record of transmittal or disclosure/release. (Should tie into the AOD requirements)
  • (Metadata) Point of record transmittal or disclosure. Address gap in metadata to maintain a record of transmittal or disclosure/release. (Should tie into the AOD requirements).
  • Point of record receipt (from external source). Gap noted – need to address in EHR-S profile.
  • (Metadata) Point of record attested accurate - verify audit record for the signature event (may be a gap).
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  • ISO Standards

  • Pan-Canadian Standards

  • IFR Standards: Record Actions

  • IFR & NPRM: Accounting of Disclosures

  • HITSP Work Products on Metadata

  • Other emerging work as appropriate

Other Gaps from IM/CDA/RM-ES Comparison and IFR Standards/Certification Evaluation
Authorship/Attestation
  • Author/Attester Roles: Identity and Role[MD1]of actor; Consenter/Patient; Scribe; Device (IEEE)

  • In IN1.8 need to address attestation done by algorithmic measure. Also clarify the concepts of “complete” and “accurate” being linked to attestation. Clarify concept of authentication vs. attestation.

  • Verify that each contributor to a document has a version retained.

  • Cloning/Copy-Paste: Author and Role issue

Amendments/Corrections/Attestation
  • Explore the next level of complexity for amendments related to exemptions, Clarify if amendment is similar to deleted, obliterated. Also – consider functionality with amendments in an HIE environment.

Identity Management
  • Patient Alias (relates identity management)

Accounting of Disclosure
HIE Gaps and Health Record Output including Disclosure to Patient
Locking Records at Encounter Level
  • Gap for preservation of records at the encounter level. (possibly related to locking records a the encounter/episode level)

Duration
  • Duration as a concept is missing. Could be calculated with start time and stop time documented or calculated in the system. Evaluate if duration should be incorporated.

Term “Use”
  • If the term “use” is not constrained, then there are gaps for use such as disclosure, export, reporting, printing, faxing, etc.

Evaluate RM-ES R1 Profile into R2 EHR-S FM
  • Monitor the EHR-S FM R2 against the RM-ES – what was added from the profile; what did not make it.
/ Divide up and monitor the activity in the EHR-S

RM-ES Workgroup Wiki: February – April 2010

  • Evaluate and develop a wiki for the RM-ES workgroup to enhance and support activities and work product development.

RM-ES Profile Release 2: August – December 2010:

  • Begin development of the RM-ES Functional Profile release 1.1
  • Begin work on an updated profile based on EHR-S FM R2 to realign the profile to the current version of the functional model and
  • Incorporate the next level of RM-ES criteria in particular those related to:
  • health information exchange
  • interoperability,
  • PHRs,
  • fraud management,
  • report on anomalies (e.g. not getting a record of a current prescription list - Ross Koppel),
  • future thinking on metadata,
  • cut and paste,
  • record management issues across multiple modules,
  • de-identification/anonymization
  • Bring in experts in Internal Audit to evaluate helpful functionality and conformance criteria.

Collaborate with other HL7 Workgroup: January – December 2010 – As Needed

  • Proactive collaborate with other HL7 working groups and project teams regarding RM-ES objectives
  • Evidentiary Medical Records WG (Under development - Began in February 2010)

RM-ES Recirculation Ballot: January – March 2010 - Completed

  • Complete recirculation ballot for RM-ES Functional Profile of the EHR-S FM Release 1 - strive to get to normative by the time FM R2
  • Move RM-ES Ballot to Publication (April 2010), post to the NIST Profile Registry, and RM-ES wiki

Meaningful Use & Standards Comments (US Realm): January - March 2010 - Completed

  • Comment on Meaningful Use and Standards and Certification for the US to advance RM-ES functionality in EHR systems.

March 22, 2010

[MD1]Is the term role problematic? How does this crosswalk with their role based access?